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OREGON HEALTH AUTHORITY,
OREGON EDUCATORS BENEFIT BOARD

DIVISION 10

DEFINITIONS

111-010-0015

Definitions

Unless the context indicates otherwise,
as used in OEBB administrative rules, the following definitions will apply:

(1) “Actuarial value”
means the expected financial value for the average member of a particular benefit
plan.

(2) “Adverse Benefit
Determination” means a denial, reduction, or termination of, or a failure
to provide or make payment (in whole or in part), for a benefit, including any such
denial, reduction, termination, or failure to provide or make payment that is based
on but not limited to:

(a) A determination of a
member’s eligibility to participate in the plan;

(b) A determination that
the benefit is not a covered benefit; or

(c) A rescission of coverage,
whether or not, in connection with rescission, there is an adverse effect on any
particular benefit.

(3) "Affidavit of Domestic
Partnership" means a document that attests the eligible employee and one other eligible
individual meet the criteria in section (15)(b).

(4) "Benefit plan" includes,
but is not limited to, insurance or other benefits including:

(h) Any other remedial care
recognized by state law, and related services and supplies;

(i) Comparable benefits for
employees who rely on spiritual means of healing; and

(j) Self-insurance programs
managed by the Board.

(5) “Benefits”
means goods and services provided under Benefit Plans.

(6) "Board" means the ten-member
board established in the Department of Administrative Services as the Oregon Educators
Benefit Board under chapter 00007, Oregon Laws 2007.

(7) “Child” means
and includes the following:

(a) An eligible employee’s,
spouse’s, or domestic partner’s biological son or daughter; adopted
child; child placed for adoption; or legally placed child, who is 25 or younger
on the first day of the month. An eligible employee must provide the required custody
or legal documents to their Educational Entity showing proof of adoption, legal
guardianship or other court order if enrolling a child for whom the employee, spouse,
or domestic partner is not the biological parent. Grandchildren are only eligible
when the eligible employee is the legal guardian or adoptive parent of the grandchild.

(b) A person who is incapable
of self-sustaining employment because of a developmental disability, mental illness,
or physical disability. There is no age limit for a dependent child who is incapable
of self-sustaining employment because of a developmental disability, mental illness,
or physical disability. When the dependent child is 26 years of age or older all
the following requirements must be met:

(A) The disability must have
existed before attaining age 26.

(B) The employee must provide
evidence to the Entity or OEBB that (1) the person had health plan coverage, group
or individual, prior to attaining age 26, and (2) health plan coverage continued
without a gap until the OEBB health plan effective date.

(C) The person’s attending
physician must submit documentation of the disability to the eligible employee’s
OEBB health insurance plan for review and approval. If the person receives health
plan approval, the health plan may review the person’s health status at any
time to determine continued OEBB coverage eligibility.

(D) The person must not have
terminated from OEBB health plan coverage after attaining the age of 26.

(c) Eligibility for coverage
under this rule includes people who may not be dependents under federal or state
tax law and may require an Entity to adjust an eligible employee’s income
based on the imputed value of the benefit.

(8) “Comparable cost
(Medical, Dental and Vision)” means that the total cost to a district for
enrollment in OEBB plans comparable in design to the district’s plan(s) do
not exceed the total cost to a district for enrollment in the district’s plan(s)
using the rate(s) in effect or proposed for the benefit plan year.

(9) “Comparable cost
(Basic and Optional Life Insurance, Accidental Death & Dismemberment, and Short
and Long Term Disability)” means that the premium rates of an OEBB plan design
option do not exceed the average, aggregate premium rates of a district’s
pre-OEBB plan design in effect the year prior to implementation.

(10) “Comparable plan
design (Medical, Dental and Vision)” means that the actuarial values of two
plan designs are within 2.5 percent higher or lower of each other.

(11) “Comparable plan
design (Basic and Optional Life Insurance and Accidental Death & Dismemberment)”
means that 90 percent of district employees can obtain a maximum benefit through
an OEBB plan design that is within $2,500 of the maximum benefit obtained through
a pre-OEBB plan design in effect the year prior to implementation.

(12) “Comparable plan
design (Short and Long Term Disability)” means 90 percent of the district
employees can obtain the same elimination period, percentage of covered compensation,
definition of covered compensation, coverage period duration, and maximum payment
per benefit period through an OEBB plan design as through a pre-OEBB plan design
in effect the year prior to implementation.

(13) “Dependent”
means and includes the eligible employee’s spouse or domestic partner, or
child as defined by OAR 111-010-0010(7), unless otherwise defined in another OEBB
rule.

(14) “Documented entity
policies” means Entities’ policies and practices that apply to an employee
group and are submitted to the Oregon Educators Benefit Board during the plan selection
process. Entities’ policies and practices must be identified and submitted
with the applicable employee group plan selections.

(15) "Eligible Domestic partner,"
unless otherwise defined by a collective bargaining agreement or documented district
policy in effect on January 31, 2008, means and includes the following:

(a) An unmarried individual
of the same sex who has entered into a “Declaration of Domestic Partnership”
with the eligible employee that is recognized under Oregon law; or

(b) An unmarried individual
of the same or opposite sex who has entered into a partnership that meets the following
criteria:

(A) Both are at least 18
years of age;

(B) Are responsible for each
other's welfare and are each other's sole domestic partners;

(C) Are not married to anyone
and have not had a spouse or another domestic partner within the prior six months.
If previously married, the six-month period starts on the final date of divorce;

(D) Share a close personal
relationship and are not related by blood closer than would bar marriage in the
State of Oregon;

(E) Have jointly shared the
same regular and permanent residence for at least six months immediately preceding
the date the Affidavit of Domestic Partnership is signed and submitted to the Educational
Entity; and

(F) Are jointly financially
responsible for basic living expenses defined as the cost of food, shelter and any
other expenses of maintaining a household. Financial information must be provided
if requested.

(G) The eligible employee
and domestic partner must jointly complete and submit to the Entity an Affidavit
of Domestic Partnership form, within five business days of the electronic enrollment
date or the date the Entity received the enrollment/change form. If the affidavit
is not received, coverage will terminate for the domestic partner retroactive to
the effective date.

(c) The eligible employee
must notify the Entity within 31 days of meeting all criteria as defined in 111-010-0015
(15)(b) or obtaining the “Declaration of Domestic Partnership” which
is recognized under Oregon law.

(16) “Educational Entity”
means public school districts (K–12), education service districts (ESDs),
community colleges and public charter schools participating in OEBB.

(17) "Eligible employee"
means and includes an employee of an Educational Entity or Local Government who
is actively working or on paid or unpaid leave that is recognized by federal or
state law, and:

(a) Is employed in a half
time or greater position or is in a job-sharing position; or

(b) Meets the definition
of an eligible employee under a separate OEBB rule or under a collective bargaining
agreement or documented district policy in effect on January 31, 2008; or

(c) Is an employee of a community
college who is covered under a collectively bargained contract and has worked a
class load of between 25 percent and 49 percent for a minimum period of two years
and is expected to continue to work a class load of at least 25 percent. Coverage
is limited to medical to include Kaiser Medical Plan 2 (where available), Moda Health
Cedar Plan, Moda Health Dogwood Plan, or Moda Health Evergreen Plan. Moda Health
Evergreen Plan can only be elected if the eligible employee is eligible for and
actively contributing to a Health Savings Account (HSA). The tiered rate structure
will apply to all medical plans.

(18) "Eligible Early Retiree"
means and includes a previously eligible employee who is:

(a) Not Medicare-eligible;
or

(b) Under 65 years old; and

(A) Receiving a service or
disability retirement allowance or pension under the Public Employees Retirement
System (PERS) or under any other retirement or disability benefit plan or system
offered by an OEBB participating organization for its employees;

(B) Eligible to receive a
service retirement allowance under PERS and has reached earliest retirement age
under ORS Chapter 238;

(C) Eligible to receive a
pension under ORS 238A.100 to 238A.245 and has reached earliest retirement age as
described in ORS 238A.165; or

(D) Eligible to receive a
service retirement allowance or pension under another retirement benefit plan or
system offered by an OEBB participating organization and has reached earliest retirement
age under the plan or system.

(19) "Employee Group" means
employees and early retirees of a similar employment type, for example administrative,
represented classified, non-represented classified, confidential, represented licensed,
or non-represented licensed, within an Entity. If one or more collective bargaining
unit exists within an employee group, each unit will be considered a separate employee
group.

(20) “Entity”
means an Educational Entity, Local Government or Special district.

(22) “Health Reimbursement
Arrangement (HRA)” means an account established and funded solely by the employer
that can be used to pay for qualified health care expenses for eligible employees
and their spouses and federal tax dependents, up to a maximum dollar amount for
a coverage period, and any unused portion of the maximum dollar amount at the end
of a coverage period is carried forward to increase the maximum reimbursement amount
in subsequent coverage periods. This definition should be interpreted to comply
with the guidelines established by the IRS for treatment of HRAs on a tax-favored
basis in Technical Release No. 2013-03, IRS Publication 969 and IRS Notice 2002-45.
HRA includes, but is not limited to, the following:

(a) “Integrated General
Purpose HRA” is an HRA that allows participants to be reimbursed for all IRS
qualified expenses and is available only to eligible employees who are enrolled
in an OEBB medical plan as the primary subscriber, or as an eligible dependent.

(b) “Integrated Post-Deductible
HRA” is an HRA that allows participants to be reimbursed for expenses up to
a certain amount, but only after the participants have met the annual deductible
on an OEBB medical plan in which the employee participant is enrolled as the primary
subscriber, or as an eligible dependent.

(c) “Limited Purpose
HRA” is an HRA that allows participants to be reimbursed for only standard
dental, vision, and orthodontia expenses and does not require the employee participant
to be enrolled in an OEBB medical plan as the primary subscriber, or as a dependent.

(d) “Non-integrated
HRA” is an HRA that allows participants to be reimbursed for all IRS qualified
expenses when the employee participant is not enrolled in an OEBB medical plan as
the primary subscriber, or as an eligible dependent.

(e) “Post-Separation/Retiree
HRA” is an HRA that allows participants to be reimbursed for qualified expenses
only after the employee separates/retires and does not require the employee participant
to be enrolled in an OEBB medical plan as the primary subscriber, or as a dependent.

(f) “Premium Only HRA”
is an HRA that allows participants to be reimbursed only for insurance premiums
paid on an after tax basis, where the employee participant has no ability to pay
the premium on a pre-tax basis and the HRA does not require the employee participant
to be enrolled in an OEBB medical plan as the primary subscriber, or as a dependent.

(23) “Health Savings
Account (HSA)” means a tax-exempt trust or custodial account that is set up
with a qualified HSA trustee to pay or reimburse certain incurred medical expenses,
as defined in 26 U.S.C. Sec. 223(d) and IRS Publication 969.

(24) “High Deductible
Health Plan (HDHP)” means a health plan that meets the criteria for a “high
deductible health plan" as outlined in 26 U.S.C. Sec. 223(c)(2). Enrollment in an
HDHP is one of the requirements that must be met in order to qualify to contribute
to a health savings account (HSA).

(27) Newly-hired and newly-eligible
employee means a benefit-eligible employee who is being hired at an Entity and has
not been employed or eligible for benefits through the hiring Entity in the past
six months, or within the same benefit Plan Year.

(28) "Non-subject District"
means a community college not yet participating in benefit plans provided by the
Oregon Educators Benefit Board, or a charter school whose employees are not considered
employees of a school district.

(31) "Provisional Non-subject
District" means a common school district, a union high school district, or an education
service district that:

(a) Was self-insured on December
31, 2006;

(b) Had an independent health
insurance trust established and functioning on December 31, 2006; or

(c) Can provide comparable
plan designs at a comparable cost as defined by sections (8) and (10) of this Rule.

(32) “Qualified Status
Change (QSC)” means a change in family or work status that allows limited
mid-year changes to benefit plans consistent with the individual event. Outside
of open enrollment, a QSC is the only time a change in enrollments can occur.

(33) “Special district”
means any district listed in ORS chapter 198 “Special Districts Generally,”
or as determined by the Board.

(34) "Spouse” means
a person who is married under the laws of the State of Oregon or under the laws
of any other state or country. The definition of spouse does not include a former
spouse and a former spouse does not qualify as a dependent.

(35) "Subject District" means
a common school district, a union high school district, or an education service
district that:

(a) Did not self-insure on
January 1, 2007;

(b) Did not have a health
trust in effect on January 1, 2007; or

(c) Does not provide comparable
plan designs at a comparable cost as defined by sections (8) and (10) of this rule.

The official copy of an Oregon Administrative Rule is
contained in the Administrative Order filed at the Archives Division,
800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the
published version are satisfied in favor of the Administrative Order.
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